Instructions for use ARIFON RETARD

Pharmacological properties of the drug Arifon retard

Indapamide ((RS)-4-chloro-3-(sulfamoyl)-N-(2,3-dihydro-1H-indol-1-yl)-benzamide) is a diuretic, antihypertensive agent. The chemical structure is a sulfonamide derivative with an indole ring. Its pharmacological properties are similar to thiazide diuretics. Due to the complex mechanism of action, Arifon has a pronounced hypotensive effect and does not cause a significant diuretic effect. The action is carried out at the level of the kidneys and blood vessels. At the kidney level, indapamide increases the excretion of sodium and chlorine ions in the urine, and to a lesser extent, the excretion of potassium and magnesium, contributing to a slight increase in diuresis. The effect of indapamide on the vascular wall is due to its high lipophilicity. Indapamide changes the transmembrane flow of ions (mainly calcium), reduces the sensitivity of the vascular wall to adrenaline and stimulates the synthesis of substances with vasodilatory activity - prostaglandin E2 and prostacyclin I2. This leads to dilation of arterioles, a decrease in peripheral vascular resistance and blood pressure. Arifon reduces left ventricular hypertrophy; does not affect lipid metabolism (TG, LDL cholesterol, HDL cholesterol) and carbohydrate metabolism, including in patients with hypertension (arterial hypertension) and diabetes mellitus, reduces the severity of microalbuminuria. The antihypertensive effect of the drug persists in patients on hemodialysis. The use of an innovative dosage form based on a hydrophilic matrix ensures uniform release of indapamide and effective blood pressure control for 24 hours, and also allows reducing the content of indapamide per tablet to 1.5 mg and thus reducing the risk of hypokalemia by 62%. When prescribed at a dose of more than 1.5 mg, the antihypertensive effect of the drug does not increase, while the likelihood of side effects increases. Indapamide is quickly and completely absorbed from the digestive tract. The maximum concentration in the blood serum after a single dose is reached after approximately 1–2 hours. The equilibrium state is achieved after 7 days from the start of treatment. 79% of indapamide binds to plasma proteins. The half-life averages 18 hours (14–24 hours). About 70% of indapamide is excreted in the urine, 22% in feces. The pharmacokinetics of the drug does not change in patients with renal failure. In patients with hepatic impairment, the use of thiazide or thiazide-like diuretics may cause the development of hepatic encephalopathy.

Arifon retard 1.5 mg 30 pcs. film-coated controlled-release tablets

pharmachologic effect

Diuretic, hypotensive.

Composition and release form Arifon retard 1.5 mg 30 pcs. film-coated controlled-release tablets

Controlled-release film-coated tablets - 1 tablet:

• active substance: indapamide - 1.5 mg;
• excipients: lactose monohydrate - 124.5 mg; hypromellose - 64 mg; magnesium stearate - 1 mg; povidone - 8.6 mg; colloidal silicon dioxide anhydrous - 0.4 mg;
• film shell: glycerol - 0.219 mg; hypromellose - 3.642 mg; macrogol 6000 - 0.219 mg; magnesium stearate - 0.219 mg; titanium dioxide - 0.701 mg.

Controlled-release film-coated tablets, 1.5 mg.

30 tablets each in a blister (PVC/Al). 1 blister along with instructions for use in a cardboard box.

During packaging (packing)/production at Serdix LLC:

Controlled-release film-coated tablets, 1.5 mg.

30 tablets in a blister (PVC/Al). 1 blister along with instructions for use in a cardboard box.

Packaging for hospitals

30 tablets each in a blister (PVC/Al). 3 blisters along with instructions for use in a cardboard pack.

30 tablets each in a blister (PVC/Al). 10 blisters per cardboard pack (the pack is not marked). 3 cardboard packs with instructions for medical use in a cardboard box.

Description of the dosage form

Round, biconvex, film-coated tablets, white.

Directions for use and doses

Inside, swallow whole, without chewing, with water, 1 tablet. per day, preferably in the morning.

When treating patients with arterial hypertension, increasing the dose of the drug does not lead to an increase in antihypertensive effect, but enhances the diuretic effect.

Elderly patients

In elderly patients, plasma creatinine levels should be monitored based on age, body weight and gender.

Arifon® retard at a dose of 1.5 mg/day (1 tablet) can be prescribed to elderly patients with normal or slightly impaired renal function.

Pharmacodynamics

Indapamide is a sulfonamide derivative with an indole ring and is similar in pharmacological properties to thiazide diuretics, which inhibit the reabsorption of sodium ions in the cortical segment of the nephron loop. At the same time, the kidneys secrete sodium, chlorine ions and, to a lesser extent, potassium and magnesium ions, which is accompanied by an increase in diuresis and a hypotensive effect.

In clinical studies of phases II and III, using indapamide as monotherapy in doses that did not have a pronounced diuretic effect, a 24-hour hypotensive effect was demonstrated.

The antihypertensive activity of indapamide is associated with an improvement in the elastic properties of large arteries, a decrease in arteriolar and total peripheral vascular resistance.

Indapamide reduces left ventricular hypertrophy.

Thiazide and thiazide-like diuretics at a certain dose reach a plateau of therapeutic effect, while the frequency of side effects continues to increase with further increases in the dose of the drug. Therefore, you should not increase the dose of the drug if a therapeutic effect is not achieved when taking the recommended dose.

In short-term, intermediate-term and long-term studies in patients with hypertension, indapamide has been shown to:

• does not affect lipid metabolism indicators, incl. on the level of triglycerides, cholesterol, LDL and HDL;
• does not affect carbohydrate metabolism, incl. in patients with diabetes mellitus.

Pharmacokinetics

In Arifon® retard tablets, the active substance is located in a special carrier matrix, which ensures gradual controlled release of indapamide in the gastrointestinal tract.

Suction

The released indapamide is quickly and completely absorbed into the gastrointestinal tract.

Eating slightly increases the absorption time of the drug without affecting the completeness of absorption.

Cmax in blood plasma is achieved 12 hours after oral administration of a single dose. With repeated doses, fluctuations in the concentration of the drug in the blood plasma in the interval between doses of the drug are smoothed out.

There is individual variability in drug absorption rates.

Distribution

About 79% of the drug binds to blood plasma proteins. T1/2 - 14–24 hours (average 18 hours).

Css is achieved after 7 days of taking the drug.

When taking the drug repeatedly, no accumulation is observed.

Metabolism

Indapamide is excreted in the form of inactive metabolites, mainly by the kidneys (70% of the administered dose) and through the intestines (22%).

Patients at high risk

In patients with renal failure, the pharmacokinetics of Arifon® retard does not change.

Indications for use Arifon retard 1.5 mg 30 pcs. film-coated controlled-release tablets

Arterial hypertension.

Contraindications

• hypersensitivity to indapamide, other sulfonamide derivatives or any of the excipients;
• severe form of renal failure (Cl creatinine
• hepatic encephalopathy or severe liver dysfunction;
• hypokalemia.

Due to the fact that the drug contains lactose, Arifon® retard is not recommended for patients with lactose intolerance, galactosemia, or glucose-galactose malabsorption.

With caution: impaired liver and kidney function, water-electrolyte imbalance, debilitated patients or patients receiving combination therapy with other antiarrhythmic drugs, diabetes mellitus, elevated uric acid levels, patients with a prolonged QT interval, hyperparathyroidism.

Due to the lack of sufficient clinical data, the drug is not recommended for use in children under 18 years of age.

Application Arifon retard 1.5 mg 30 pcs. film-coated controlled-release tablets during pregnancy and lactation

Pregnancy

As a general rule, diuretics should not be prescribed during pregnancy. These drugs should not be used to treat physiological edema during pregnancy. Diuretics can cause fetoplacental ischemia and lead to impaired fetal development.

Breastfeeding period

It is not recommended to prescribe Arifon® retard to nursing mothers (indapamide is excreted in breast milk).

special instructions

Liver dysfunction

When prescribing thiazide and thiazide-like diuretics in patients with impaired liver function, hepatic encephalopathy may develop, especially in the case of electrolyte imbalance. In this case, diuretics should be stopped immediately.

Photosensitivity

Cases of photosensitivity reactions have been reported while taking thiazide and thiazide-like diuretics. If photosensitivity reactions develop while taking the drug, treatment should be discontinued. If it is necessary to continue diuretic therapy, it is recommended to protect the skin from exposure to sunlight or artificial UV rays.

Water and electrolyte balance:

• Content of sodium ions in blood plasma. Before starting treatment, it is necessary to determine the content of sodium ions in the blood plasma. While taking the drug, this indicator should be regularly monitored. All diuretic drugs can cause hyponatremia, sometimes leading to extremely serious consequences. Constant monitoring of the content of sodium ions is necessary, because Initially, a decrease in sodium concentration in the blood plasma may not be accompanied by the appearance of pathological symptoms. The most careful monitoring of sodium ion content is indicated for patients with liver cirrhosis and the elderly.
• Content of potassium ions in blood plasma. When treating with thiazide and thiazide-like diuretics, the main risk is a sharp decrease in the level of potassium in the blood plasma and the development of hypokalemia. The risk of hypokalemia must be avoided (

In addition, patients with an increased QT interval are at increased risk, and it does not matter whether this increase is caused by congenital causes or the effect of drugs.

Hypokalemia, like bradycardia, is a condition that contributes to the development of severe arrhythmias and especially arrhythmias, which can be fatal. In all the cases described above, it is necessary to regularly monitor the potassium content in the blood plasma. The first measurement of the concentration of potassium ions in the blood must be carried out within the first week from the start of treatment.

If hypokalemia occurs, appropriate treatment should be prescribed.

• Calcium content in blood plasma. It should be borne in mind that thiazide and thiazide-like diuretics can reduce the excretion of calcium ions by the kidneys, leading to a slight and temporary increase in the concentration of calcium in the blood plasma. Severe hypercalcemia may be a consequence of previously undiagnosed hyperparathyroidism.

Diuretics should be discontinued before testing parathyroid function.

• Glucose content in blood plasma. It is necessary to monitor blood glucose levels in patients with diabetes mellitus, especially in the presence of hypokalemia.
• Uric acid. In patients with gout, the frequency of attacks may increase or the course of gout may worsen.

Diuretics and kidney function. Thiazide and thiazide-like diuretics are fully effective only in patients with normal or slightly impaired renal function (plasma creatinine in adults below 25 mg/l or 220 µmol/l). In elderly patients, normal plasma creatinine levels are calculated taking into account age, body weight and gender.

It should be taken into account that at the beginning of treatment, patients may experience a decrease in glomerular filtration rate due to hypovolemia, which in turn is caused by the loss of fluid and sodium ions while taking diuretic drugs. As a result, the concentration of urea and creatinine in the blood plasma may increase. If renal function is not impaired, such temporary functional renal failure, as a rule, passes without consequences, however, with existing renal failure, the patient's condition may worsen.

Athletes

The active substance included in the drug Arifon® retard can give a positive result during doping control in athletes.

Impact on the ability to drive a car and perform work that requires increased speed of physical and mental reactions

The action of the substances included in the drug Arifon® retard does not lead to impairment of psychomotor reactions. However, some people may develop different individual reactions in response to lowering blood pressure, especially at the beginning of therapy or when other antihypertensive drugs are added to therapy. In this case, the ability to drive a car or operate other machinery may be reduced.

Overdose

Indapamide, even in very high doses (up to 40 mg, i.e. 27 times the therapeutic dose), does not have a toxic effect.

Signs of acute drug poisoning are primarily associated with water and electrolyte imbalance (hyponatremia, hypokalemia). Clinical symptoms of overdose may include nausea, vomiting, decreased blood pressure, convulsions, dizziness, drowsiness, confusion, polyuria or oliguria leading to anuria (due to hypovolemia).

Emergency measures are limited to removing the drug from the body: gastric lavage and/or administration of activated charcoal, followed by restoration of water and electrolyte balance.

Side effects Arifon retard 1.5 mg 30 pcs. film-coated controlled-release tablets

Most adverse reactions (laboratory and clinical indicators) are dose-dependent.

The frequency of adverse reactions that can be caused by thiazide-like diuretics, including indapamide, is given in the following gradation: very often (≥1/10); often (≥1/100,

From the circulatory and lymphatic system: very rarely - thrombocytopenia, leukopenia, agranulocytosis, aplastic anemia, hemolytic anemia.

From the side of the central nervous system: rarely - asthenia, headache, paresthesia, vertigo; unspecified frequency - fainting.

From the cardiovascular system: very rarely - arrhythmia, marked decrease in blood pressure; unspecified frequency - ari (possibly fatal).

From the digestive system: infrequently - vomiting; rarely - nausea, constipation, dryness of the oral mucosa; very rarely - pancreatitis.

From the urinary system: very rarely - renal failure.

From the liver and biliary tract: very rarely - impaired liver function; unspecified frequency - the possibility of developing hepatic encephalopathy in case of liver failure, hepatitis.

On the part of the skin and subcutaneous fat: hypersensitivity reactions, mainly dermatological, in patients with a predisposition to allergic and asthmatic reactions: often - maculopapular rash; uncommon - hemorrhagic vasculitis; very rarely - angioedema and/or urticaria, toxic epidermal necrolysis, Stevens-Johnson syndrome; unspecified frequency - in patients with an acute form of systemic lupus erythematosus, the course of the disease may worsen. Cases of photosensitivity reactions have been described.

Laboratory indicators: unspecified frequency - increase in QT interval on the ECG (see "Special instructions"); increased concentrations of uric acid and glucose in the blood: thiazide and thiazide-like diuretics should be used with caution in patients with gout and diabetes mellitus; increased activity of liver transaminases.

In clinical studies, hypokalemia (plasma potassium level less than 3.4 mmol/l) was observed in 10% of patients and less than 3.2 mmol/l in 4% of patients after 4–6 weeks of treatment. After 12 weeks of therapy, the potassium content in the blood plasma decreased by an average of 0.23 mmol/l.

Very rarely - hypercalcemia; unspecified frequency - a decrease in potassium levels and the development of hypokalemia, especially significant for patients at risk (see “Special Instructions”); hyponatremia, accompanied by hypovolemia, dehydration and orthostatic hypotension. Simultaneous hypochloremia can lead to compensatory metabolic alkalosis (the likelihood and severity of this effect is low).

Drug interactions

Undesirable combination of drugs

Lithium preparations. With the simultaneous use of indapamide and lithium preparations, an increase in the concentration of lithium in the blood plasma may be observed due to a decrease in its excretion, accompanied by the appearance of signs of overdose. If necessary, diuretic drugs can be used in combination with lithium drugs, and the dose of the drugs should be carefully selected, constantly monitoring the lithium content in the blood plasma.

Combination of drugs requiring special attention

Drugs that can cause aritis:

• class IA antiarrhythmic drugs (quinidine, hydroquinidine, disopyramide);
• class III antiarrhythmic drugs (amiodarone, sotalol, dofetilide, ibutilide);
• some neuroleptics: phenothiazines (chlorpromazine, cyamemazine, levomepromazine, thioridazine, trifluoroperazine), benzamides (amisulpride, sulpiride, sultopride, tiapride), butyrophenones (droperidol, haloperidol);
• others: bepridil, cisapride, difemanil, erythromycin (iv), halofantrine, mizolastine, pentamidine, sparfloxacin, moxifloxacin, astemizole, vincamine (iv).

Increased risk of ventricular arrhythmias, especially arrhythmias (risk factor - hypokalemia).

The level of potassium in the blood plasma should be determined and, if necessary, adjusted before starting combination therapy with indapamide and the above drugs. It is necessary to monitor the patient’s clinical condition, monitor the level of electrolytes in the blood plasma, and ECG indicators.

In patients with hypokalemia, drugs that do not cause ari should be used.

NSAIDs (if administered systemically), including selective COX-2 inhibitors, high doses of salicylates (≥3 g/day). The antihypertensive effect of indapamide may be reduced. With significant fluid loss, acute renal failure may develop (due to decreased glomerular filtration). Patients need to compensate for fluid loss and carefully monitor renal function at the beginning of treatment.

ACE inhibitors. Prescribing ACE inhibitors to patients with a reduced concentration of sodium ions in the blood (especially patients with renal artery stenosis) is accompanied by a risk of sudden arterial hypotension and/or acute renal failure.

Patients with arterial hypertension and possibly reduced levels of sodium ions in the blood plasma due to diuretics should:

• 3 days before starting treatment with an ACE inhibitor, stop taking diuretics. In the future, if necessary, diuretics can be resumed;
• or begin ACE inhibitor therapy with low doses, followed by a gradual increase in dose if necessary.

In chronic heart failure, treatment with ACE inhibitors should begin with low doses with a possible preliminary reduction in the doses of diuretics.

In all cases, in the first week of taking ACE inhibitors in patients, it is necessary to monitor renal function (plasma creatinine content).

Other drugs that can cause hypokalemia: amphotericin B (iv), corticosteroids and mineralocorticosteroids (when administered systemically), tetracosactide, laxatives that stimulate intestinal motility. Increased risk of hypokalemia (additive effect).

Constant monitoring of the level of potassium in the blood plasma is necessary, and, if necessary, its correction. Particular attention should be paid to patients simultaneously receiving cardiac glycosides. It is recommended to use laxatives that do not stimulate intestinal motility.

Baclofen. There is an increase in the hypotensive effect.

Patients need to compensate for fluid loss and carefully monitor renal function at the beginning of treatment.

Cardiac glycosides. Hypokalemia enhances the toxic effect of cardiac glycosides.

With the simultaneous use of indapamide and cardiac glycosides, the level of potassium in the blood plasma, ECG parameters should be monitored, and, if necessary, therapy should be adjusted.

Combination of drugs requiring attention

Potassium-sparing diuretics (amiloride, spironolactone, triamterene). Combination therapy with indapamide and potassium-sparing diuretics is advisable in some patients, but the possibility of developing hypokalemia (especially in patients with diabetes mellitus and patients with renal failure) or hyperkalemia cannot be excluded.

It is necessary to monitor the level of potassium in the blood plasma, ECG indicators and, if necessary, adjust therapy.

Metformin. Functional renal failure, which can occur against the background of diuretics, especially loop diuretics, with simultaneous administration of metformin increases the risk of developing lactic acidosis.

Metformin should not be used if creatinine levels exceed 15 mg/L (135 µmol/L) in men and 12 mg/L (110 µmol/L) in women.

Iodinated contrast agents. Dehydration while taking diuretics increases the risk of developing acute renal failure, especially when using high doses of iodinated contrast agents.

Before using iodine-containing contrast agents, patients must compensate for fluid loss.

Tricyclic antidepressants, antipsychotics (neuroleptics). Drugs in these classes enhance the antihypertensive effect of indapamide and increase the risk of orthostatic hypotension (additive effect).

Calcium salts. With simultaneous administration, hypercalcemia may develop due to a decrease in the excretion of calcium ions by the kidneys.

Cyclosporine, tacrolimus. It is possible to increase the creatinine content in the blood plasma without changing the concentration of circulating cyclosporine, even with normal fluid and sodium ion levels.

Corticosteroid drugs, tetracosactide (if administered systemically). Reduced hypotensive effect (retention of fluid and sodium ions as a result of the action of corticosteroids).

Side effects of the drug Arifon retard

Considering the fact that most of the side effects of indapamide are dose-dependent, reducing the content of the active substance in the Arifona retard tablet to 1.5 mg made it possible to significantly reduce the likelihood of developing side effects. Hypokalemia may develop (especially in patients at risk); hyponatremia, accompanied by hypovolemia and dehydration with the possible development of orthostatic hypotension. Concomitant loss of chloride ions may secondary cause compensatory metabolic alkalosis. Hyperuricemia and hyperglycemia are possible; hypercalcemia is very rare. Hematological disorders develop extremely rarely: leukopenia, thrombocytopenia, agranulocytosis, hemolytic or aplastic anemia. From the digestive tract, nausea, constipation, dry mouth are observed, in isolated cases - pancreatitis, in patients with liver failure - hepatic encephalopathy. From the central nervous system - dizziness, asthenia, paresthesia, headache. Hypersensitivity reactions are possible in patients prone to them (maculopapular rash, purpura, exacerbation of systemic lupus erythematosus).

Special instructions for the use of the drug Arifon retard

Before starting treatment and during the period of use of the drug, the level of potassium, sodium, calcium and glucose in the blood plasma should be monitored, kidney function should be monitored (creatinine and urea levels in the blood plasma) and ECG monitoring, especially in cases of water-electrolyte balance disorders and gout , diabetes mellitus, liver or kidney failure, in elderly patients. Hypokalemia (less than 3.4 mmol/l) is a predisposing factor in the development of dangerous arrhythmias and increases the toxicity of cardiac glycosides. Such patients should more often monitor the level of potassium in the blood serum and correct it, especially in patients at risk (elderly people, with an unbalanced diet, in patients with liver cirrhosis, coronary artery diseases, heart failure, with a prolongation of the QT by ECG). The possible development of hyperuricemia contributes to the occurrence of gout attacks. The use of the drug in athletes may cause a positive reaction during doping control. The drug is not recommended for use in children. Arifon retard does not interfere with psychomotor reactions and can affect the ability to drive vehicles and operate dangerous machinery only in the event of a sharp decrease in blood pressure. It is not recommended to prescribe the drug during pregnancy and breastfeeding.

Arifon® retard

Not recommended combination of drugs

With the simultaneous use of indapamide and lithium preparations, an increase in the concentration of lithium in the blood plasma may be observed due to a decrease in its excretion, accompanied by the appearance of signs of overdose. If necessary, diuretic drugs can be used in combination with lithium drugs, and the dose of the drugs should be carefully selected, constantly monitoring the lithium content in the blood plasma.

Combinations requiring special control

Drugs that can cause aritis:

- class IA antiarrhythmic drugs (quinidine, hydroquinidine, disopyramide);

- class III antiarrhythmic drugs (amiodarone, sotalol, dofetilide, ibutilide);

- some neuroleptics: phenothiazines (chlorpromazine, cyamemazine, levomepromazine, thioridazine, trifluoroperazine), benzamides (amisulpride, sulpiride, sultopride, tiapride), butyrophenones (droperidol, haloperidol);

- others: bepridil, cisapride, difemanil, erythromycin (iv), halofantrine, mizolastine, pentamidine, sparfloxacin, moxifloxacin, astemizole, vincamine (iv).

Hypokalemia increases the risk of developing ventricular arrhythmias, especially arrhythmias. The level of potassium in the blood plasma should be determined and, if necessary, adjusted before starting combination therapy with indapamide and the above drugs. It is necessary to monitor the patient’s clinical condition, monitor the level of electrolytes in the blood plasma, and ECG indicators.

In patients with hypokalemia, drugs that do not cause ari should be used.

When used simultaneously with NSAIDs (for systemic use), including selective COX-2 inhibitors, high doses of salicylates (more than 3 g/day), the hypotensive effect of indapamide may be reduced. With significant fluid loss, acute renal failure may develop (due to decreased glomerular filtration). If it is necessary to prescribe NSAIDs during therapy with Arifon retard, the loss of water should be compensated and renal function should be carefully monitored.

When indapamide is used concomitantly with ACE inhibitors, hyponatremia in patients receiving ACE inhibitors increases the risk of sudden arterial hypotension and/or acute renal failure (especially with renal artery stenosis). Patients with arterial hypertension and a reduced content of sodium ions in the blood plasma due to diuretics should:

- 3 days before starting treatment with ACE inhibitors, stop taking diuretics. In the future, if necessary, resume taking diuretics;

- or begin therapy with ACE inhibitors with low, gradually increasing doses of ACE inhibitors.

In chronic heart failure, treatment should begin with low doses of ACE inhibitors, after first reducing the dose of diuretics. In all cases, in the first week of taking ACE inhibitors, it is necessary to monitor renal function (plasma creatinine content).

When using indapamide simultaneously with other drugs that can cause hypokalemia, incl. with amphotericin B (iv), gluco- and mineralocorticoids (with systemic use), tetracosactide, laxatives that stimulate intestinal motility, the risk of hypokalemia increases due to an additive effect (constant monitoring of the level of potassium in the blood plasma is required and, if necessary, appropriate treatment). Particular attention should be paid to patients simultaneously receiving cardiac glycosides. It is recommended to use laxatives that do not stimulate intestinal motility.

With simultaneous use of indapamide with baclofen, an increase in the hypotensive effect is observed (it is necessary to compensate for the loss of water and carefully monitor renal function at the beginning of treatment).

When used simultaneously with cardiac glycosides, the toxic effect of the latter may be enhanced due to hypokalemia (it is necessary to monitor the level of potassium in the blood plasma and ECG readings and, if necessary, adjust therapy).

Combinations requiring special attention

Concomitant therapy with indapamide and potassium-sparing diuretics is advisable in some patients, but this does not exclude the possibility of developing hypokalemia (especially in patients with diabetes mellitus and patients with renal failure) or hyperkalemia. It is necessary to monitor the level of potassium in the blood plasma, ECG indicators and, if necessary, adjust therapy.

Functional renal failure, which can occur against the background of diuretics, especially loop diuretics, with simultaneous administration of metformin increases the risk of developing lactic acidosis. It is not recommended to use metformin in combination with Arifon retard if the creatinine level is more than 15 mg/l (135 µmol/l) in men and 12 mg/l (110 µmol/l) in women.

Dehydration while taking diuretics increases the risk of developing acute renal failure, especially when using high doses of iodinated contrast agents. Before using iodine-containing contrast agents, patients must compensate for fluid loss.

With the simultaneous use of indapamide and tricyclic antidepressants, antipsychotics, there is an increase in the hypotensive effect of indapamide and an increased risk of developing orthostatic hypotension (additive effect).

With the simultaneous use of thiazide diuretics and calcium salts, hypercalcemia may develop due to a decrease in the excretion of calcium ions in the urine.

With the simultaneous use of thiazide diuretics with cyclosporine and tacrolimus, it is possible to increase the creatinine content in the blood plasma without changing the concentration of circulating cyclosporine, even with normal fluid and sodium ion levels.

With the simultaneous use of thiazide diuretics with GCS, tetracosactide for systemic use, a decrease in the hypotensive effect is observed due to the retention of water and sodium ions under the influence of GCS.

Interactions of the drug Arifon retard

The simultaneous administration of the following drugs with Arifon retard is not recommended: lithium salts (an increase in the concentration of lithium in the blood serum with the development of toxic manifestations; if it is necessary to prescribe such a combination, the level of lithium in the blood serum should be monitored), astemizole, bepridil, erythromycin, halofantrine, pentamidine, sultopride , terfenadine, vincamine (increased risk of developing ventricular flutter-fibrillation, especially in the presence of hypokalemia, bradycardia or prolongation of the QT ). The following drugs should be prescribed with caution along with Arifon retard: NSAIDs for systemic use, including salicylates in high doses (possible development of acute renal failure in patients with dehydration; it is necessary to monitor kidney function and rehydrate), drugs that reduce the level of potassium in the blood - amphotericin B with intravenous administration, gluco- and mineralocorticoids for oral administration, tetracosactide, laxatives that stimulate peristalsis (increase the risk of hypokalemia), corticosteroids, tetracosactide (reduced antihypertensive effect as a result of water and sodium retention in the body), cardiac glycosides ( hypokalemia increases the risk of developing toxic effects of digitalis), potassium-sparing diuretics - amiloride, triamterene, spironolactone (possible development of hyperkalemia in patients with renal failure), ACE inhibitors (possible development of sudden arterial hypotension or renal failure due to hyponatremia in patients with dehydration; it is recommended to stop using the diuretic 3 days before prescribing ACE inhibitors, then, if necessary, the diuretic is resumed), antiarrhythmic drugs - quinidine, hydroquinidine, disopyramide, bretylium tosylate, sotalol and amiodarone (the risk of developing paroxysms of flutter-ventricular fibrillation increases, especially in the presence of hypokalemia or prolongation of the QT interval), metformin (risk of developing lactic acidosis due to the development of renal failure), iodine-containing contrast agents (with dehydration caused by the use of diuretics, the risk of developing acute renal failure increases; fluid and electrolyte balance should be restored before contrast administration), tricyclic antidepressants ( potentiate the hypotensive effect and increase the risk of developing orthostatic hypotension), calcium salts (risk of developing hypercalcemia), cyclosporine (increased serum creatinine levels), estrogens (due to fluid retention in the body, the hypotensive effect of the drug may be reduced).

Arifon retard

Trade name: Arifon retard International name: Indapamide

Release form: controlled-release film-coated tablets 1.5 mg (blisters)

Composition: indapamide 1.5 mg

Pharmacological group: diuretic

Pharmacological group according to ATK: C03BA11 (Indapamide)

Pharmacological action: BMCC selective, vasodilating, hypotensive, diuretic,

Description: Controlled-release tablets, white, round, biconvex, film-coated.

Ingredients: 1 tab. contains - indapamide, 1.5 mg Excipients: lactose, hydroxypropyl methylcellulose, povidone, colloidal silicon anhydride, magnesium stearate, macrogol 6000, glycerol, titanium dioxide.

Indications: - arterial hypertension.

Dosage regimen: Arifon retard is prescribed orally, 1 tablet/day, preferably in the morning.

Contraindications: - severe renal failure, - hepatic encephalopathy, - hypokalemia, - simultaneous use with drugs that prolong the QT interval, - hypersensitivity to indapamide and other sulfonamide derivatives.

Side effects: On the water-electrolyte balance: a decrease in potassium levels and the development of hypokalemia (especially pronounced in patients at risk) are possible. According to clinical studies, hypokalemia (the concentration of potassium ions in the blood plasma. Hyponatremia is possible, accompanied by hypovolemia, dehydration of the body and orthostatic hypotension. The simultaneous loss of chlorine ions can lead to compensatory metabolic alkalosis, the frequency and severity of which is low. Extremely rare - an increase in calcium levels in the body .

From the metabolic side: an increase in the content of urea and glucose in the blood plasma is possible. From the hematopoietic system: rarely - thrombocytopenia, leukopenia, aplastic anemia, hemolytic anemia, agranulocytosis, bone marrow aplasia. From the digestive system: rarely - nausea, constipation, dry mouth, extremely rarely - pancreatitis. Allergic reactions: in patients predisposed to allergic reactions and the development of attacks of bronchial asthma, skin manifestations of hypersensitivity to the drug are possible, rarely - hemorrhagic vasculitis, exacerbation of disseminated lupus erythematosus. From the central nervous system and peripheral nervous system: rarely - dizziness, asthenia, paresthesia, headache (these effects usually disappear when the dose of the drug is reduced). Patients with liver failure may develop hepatic encephalopathy. Most side effects are dose dependent.

Overdose of Indapamide, even in very high concentrations (up to 40 mg, i.e. 27 times more than the therapeutic dose), does not have a toxic effect. Symptoms: possible disturbances in water and electrolyte balance (hyponatremia, hypokalemia), nausea, vomiting, arterial hypotension, convulsions, dizziness, drowsiness, confusion, polyuria or oliguria ending in anuria (due to hypovolemia). Treatment: urgent measures aimed at removing the drug from the body: gastric lavage and/or administration of activated charcoal, followed by restoration of normal water and electrolyte balance.

Pharmacodynamics: Antihypertensive (diuretic) drug, a sulfonamide derivative containing an indole ring. In terms of pharmacological properties, indapamide is close to thiazide diuretics, the action of which is associated with inhibition of the reverse absorption of sodium ions in the cortical segment of the nephron loop. Indapamide increases the urinary excretion of sodium, chlorine and, to a lesser extent, potassium and magnesium ions, which is accompanied by increased diuresis. Indapamide has an antihypertensive effect in doses that do not have a pronounced diuretic effect. In addition, the hypotensive effect is associated with the ability of the drug to increase the elasticity of arterial walls and reduce peripheral vascular resistance. The mechanism of action of indapamide is due to a change in the transmembrane current of ions (primarily calcium), which leads to relaxation of vascular smooth muscle cells, as well as increased synthesis of prostaglandins PGE2 and prostacyclin PGI2 (vasodilator and platelet aggregation inhibitor). The drug helps reduce hypertrophy of the left ventricle of the heart. Clinical trials of Arifon retard (phase II and III) showed that monotherapy develops a persistent hypotensive effect that persists for 24 hours, while a moderate increase in diuresis was observed. Regardless of the duration of use, Arifon retard does not affect the content of lipids in the blood plasma (triglycerides, LDL-C, HDL-C), does not change the parameters of carbohydrate metabolism (including in patients with arterial hypertension and diabetes mellitus). Indapamide is effective in patients with one kidney. Indapamide has an antihypertensive effect in doses that do not have a pronounced diuretic effect. When indapamide is used in high doses, the hypotensive effect does not increase, but diuresis increases.

Pharmacokinetics: Absorption In Arifona retard tablets, the active substance is located in a special carrier matrix, which ensures gradual release of indapamide in the gastrointestinal tract, with Cmax achieved 12 hours after a single oral dose of 1 tablet (1.5 mg). With repeated doses, fluctuations in the concentration of indapamide in the blood plasma in the interval between two doses decrease. Eating slightly slows down the rate of absorption of the drug, but does not affect the amount of absorbed substance. Distribution Plasma protein binding is about 79%. The equilibrium state is established after 7 days of regular use. When taking Arifon retard again, there is no accumulation of indapamide in the body. Metabolism and excretion Indapamide undergoes biotransformation and is excreted in the form of inactive metabolites, mainly in urine - 70% and feces - 22%. T1/2 is 14-24 hours (average 18 hours). Pharmacokinetics in special clinical cases In patients with renal failure, the pharmacokinetic parameters of Arifon retard do not change.

Special instructions: Pregnancy and lactation As a rule, Arifon retard is not recommended for use during pregnancy, incl. to relieve physiological edema. It should be borne in mind that diuretics can cause fetoplacental ischemia and lead to impaired fetal development. Due to the fact that indapamide is excreted in breast milk, it is also not recommended to prescribe the drug during breastfeeding.

The simultaneous use of Arifon retard and drugs that prolong the QT interval should be avoided. When prescribing Arifon retard to patients with diabetes, it is extremely important to control glucose levels, especially in the presence of hypokalemia. Patients with elevated uric acid levels tend to have more gout attacks. When thiazide diuretics are prescribed to patients with liver failure, hepatic encephalopathy may develop. In such cases, the drug should be stopped immediately. Thiazide diuretics are fully effective only in the absence of impairment or in moderately severe impairment of renal function (blood creatinine less than 2.5 mg/dL or 220 µmol/L). In elderly patients, the normal level of creatinine in blood plasma is calculated taking into account the age, body weight and gender of the patient using the Cockcroft formula: (140 - age) x body weight (kg) CC (ml/min) =———————— ———— 0.814 x serum creatinine (µmol/l) This formula is used to calculate creatinine levels in men; for women, the final result should be multiplied by 0.85. It should be taken into account that at the beginning of treatment, patients may experience a decrease in glomerular filtration due to hypovolemia, which is caused by the loss of water and sodium ions while taking diuretics. As a result, the concentration of urea and creatinine in the blood plasma may increase. If kidney function is not impaired, such temporary renal failure usually resolves without consequences. However, with existing renal failure, the patient's condition may worsen. During therapy with Arifon retard, exacerbation of disseminated lupus erythematosus is possible. Before starting treatment, the content of sodium ions in the blood plasma should be determined. During treatment, regular monitoring of this indicator is necessary, since initially a decrease in sodium concentration in the blood plasma may not be accompanied by the appearance of pathological symptoms. This analysis should be performed especially often in patients with liver cirrhosis and in the elderly. When treating with thiazide diuretics, the main risk is a sharp decrease in the content of potassium ions and the development of hypokalemia. In a certain category of patients, especially the elderly, weakened or receiving concomitant therapy, with cirrhosis of the liver with developed edema or ascites, coronary artery disease, chronic heart failure, it is necessary to avoid the development of hypokalemia (Hypokalemia, like bradycardia, is a condition that contributes to the development of severe cardiac arrhythmias, especially the “pirouette” type, often leading to death. In all the cases described above, it is necessary to more often determine the content of potassium ions in the blood plasma. The first measurement of the concentration of potassium ions in the blood should be carried out within the first week from the start of treatment. When hypokalemia should be treated appropriately, while avoiding the use of drugs that cause arrhythmias. If such a rhythm disorder occurs, antiarrhythmic drugs should not be used, but an artificial pacemaker should be installed. It should be borne in mind that thiazide diuretics can reduce the excretion of calcium ions in the urine, resulting in mild and temporary hypercalcemia. Severe hypercalcemia may be a consequence of previously undiagnosed hyperparathyroidism. Diuretics should be discontinued before starting a study of parathyroid function. If it is necessary to prescribe laxatives during therapy with Arifon retard, drugs that do not affect intestinal motility should be prescribed. While taking indapamide, a positive result is possible during doping control in athletes. Increasing the dose of thiazide diuretics above the optimal one is not accompanied by an increase in antihypertensive effect, but may be accompanied by the occurrence of severe adverse reactions. If therapy with thiazide diuretics does not lead to the desired therapeutic effect, the dose of the drug should not be increased. When used simultaneously with other antihypertensive drugs, the dose of Arifon retard should be reduced, at least at the beginning of treatment.

Use in pediatrics Due to the lack of sufficient clinical data, the drug is not recommended for use in children and adolescents under 18 years of age. Effect on the ability to drive vehicles and operate machinery The action of the substances included in Arifon retard does not lead to impaired psychomotor reactions. However, it should be borne in mind that in some cases, when blood pressure decreases, individual reactions may occur (especially at the beginning of therapy or when combining several antihypertensive drugs). In this case, the ability to engage in activities that require increased attention and speed of psychomotor reactions may be reduced.

Interaction: Not recommended combination of drugs With the simultaneous use of thiazide diuretics and lithium preparations, an increase in the concentration of lithium in the blood plasma is possible, accompanied by the appearance of signs of overdose (due to a decrease in the excretion of lithium in the urine). If it is necessary to prescribe this combination, the concentration of lithium in the blood plasma should be monitored. With the simultaneous use of diuretics with astemizole, bepridil, erythromycin (iv), halofantrine, pentamidine, sultopride, terfenadine, vincamine, the likelihood of ari increases. Hypokalemia, bradycardia, or prolonged QT interval may contribute to this condition.

Combinations requiring special monitoring When used simultaneously with NSAIDs (for systemic use), high doses of salicylates, the hypotensive effect of indapamide may be reduced. With significant fluid loss, acute renal failure may develop (due to a sharp decrease in glomerular filtration). If it is necessary to prescribe NSAIDs during therapy with Arifon retard, the loss of water should be compensated and renal function should be carefully monitored. When using indapamide simultaneously with other drugs that can cause hypokalemia, incl. with amphotericin B (iv), gluco- and mineralocorticoids (with systemic use), tetracosactide, laxatives that stimulate intestinal motility, the risk of hypokalemia increases (constant monitoring of the level of potassium in the blood plasma and, if necessary, appropriate treatment is required) . With the simultaneous use of thiazide diuretics with GCS, tetracosactide for systemic use, a decrease in the hypotensive effect is observed due to the retention of water and sodium ions under the influence of GCS. When used simultaneously with cardiac glycosides, the toxic effect of the latter may be enhanced (it is necessary to monitor the level of potassium in the blood plasma and ECG readings). With simultaneous use of indapamide with baclofen, an increase in the hypotensive effect is observed (it is necessary to compensate for the loss of water and carefully monitor renal function at the beginning of treatment). With the simultaneous use of indapamide and potassium-sparing diuretics (including amiloride, spironolactone, triamterene), the possibility of developing hypokalemia or hyperkalemia cannot be completely excluded, especially in patients with diabetes mellitus and renal failure. In such cases, the level of potassium in the blood plasma, ECG parameters should be monitored and, if necessary, therapy should be adjusted. When indapamide is used concomitantly with ACE inhibitors, hyponatremia in patients receiving ACE inhibitors increases the risk of sudden arterial hypotension and/or acute renal failure (especially with renal artery stenosis). Patients with essential arterial hypertension and a reduced content of sodium ions in the blood plasma due to diuretics should stop taking diuretics 3 days before starting treatment with ACE inhibitors. In the future, if necessary, resume taking diuretics. In addition, low, gradually increasing doses of ACE inhibitors are prescribed. In chronic heart failure, treatment should begin with low doses of ACE inhibitors, after first reducing the dose of diuretics. In all cases, in the first week of taking ACE inhibitors, it is necessary to monitor renal function (plasma creatinine content). With the simultaneous administration of indapamide and antiarrhythmic drugs that can cause arrhythmia (including quinidine, hydroquinidine, disopyramide, amiodarone, bretylium, sotalol), the risk of developing this condition increases (especially against the background of hypokalemia, bradycardia, and an initially prolonged QT interval). If it is necessary to prescribe this combination, the level of potassium in the blood plasma and the QT interval should be monitored, adjusting the dosage regimen. With the simultaneous use of diuretics and metformin, the appearance of lactic acidosis is possible, which is apparently associated with the development of functional renal failure caused by the action of diuretics (mostly “loop”). It is not recommended to use metformin in combination with Arifon retard if the creatinine level is more than 1.5 mg/dl (135 µmol/l) in men and 1.2 mg/dl (110 µmol/l) in women. When using iodine-containing X-ray contrast agents, it should be borne in mind that the diuretic effect of indapamide increases the risk of developing renal failure. This risk is especially high when using iodinated contrast agents in high doses. Before using iodine-containing radiocontrast agents, patients need to restore fluid loss. With the simultaneous use of indapamide and tricyclic antidepressants such as imipramine, an increased hypotensive effect and an increased risk of developing orthostatic hypotension are observed. With the simultaneous use of thiazide diuretics and calcium salts, hypercalcemia may develop due to a decrease in the excretion of calcium ions in the urine. With the simultaneous use of indapamide and cyclosporine, an increase in the content of creatinine in the blood plasma is possible, which is observed even with normal levels of water and sodium ions.

Storage conditions: The drug should be stored at a temperature not exceeding 30 degrees. C.

Shelf life: Shelf life - 2 years.

Dispensed from pharmacies: Dispensed by prescription.

Drug registration number: P No. 015249/01

Date of registration (re-registration) of the drug: 12/15/2006

Overdose of the drug Arifon retard, symptoms and treatment

Symptoms of overdose (taking very large doses) are primarily manifestations of water and electrolyte disturbances (hyponatremia, hypokalemia). Clinically, nausea, vomiting, hypotension, convulsions, drowsiness, dizziness, polyuria or oliguria up to anuria (which is a consequence of hypovolemia) may occur. First aid measures include rapid elimination of the drug by gastric lavage and/or administration of activated carbon, followed by restoration of water and electrolyte balance in a hospital setting.